KIDNEYBLOG

Sunday, August 5, 2018

As a nephrologist, I encourage patients to ask questions about their disease. Although in an encounter, it is impossible to cover all aspects of a disease or condition, successful therapy depends, not on the few moments the patient spends in the office, but on what is done the rest of the time. Understanding the needs of the patient is crucial to providing effective care. Management of a chronic disease takes engagement and immersion into a lifestyle that promotes good health. Together, the patient and doctor are sharing information that must lead to well informed decisions that can promote this engagement. This takes trust, mutual understanding and caring.

We demand a great deal from the kidney patient. Take diet for instance. The kidney patient must be vigilant with respect to diet. We often discuss modifications in the intake of salt, potassium, fluids, proteins, carbohydrates, fats and sugars. It is can be quite daunting, but there are ways to create a diet that is healthy, promotes good health, and is also delicious. We also ask patients to stay away from cigarettes, get plenty of exercise, and avoid several medications while adhering to prescriptions for others.

Asking questions tells the doctor one is engaged and ready to move forward with a healthy lifestyle. It also lets me fill in the gaps, so that patient can leave the office well informed.

Before your visit, NEPHROQUEST will help you get introductory information you can use to engage in aa discussion with your doctor. It will help fill in the gaps, in case you remember a question you forgot to ask. NEPHROQUEST is powered by Kidney Associates, my clinical practice. Many of the questions here are often asked by my patients.

If you have a question that has not been answered, just email me at fadem@kidneyassociates.com with the subject line NEPHROQUEST. Keep in mind that this site will be widely read by the public, and it will be inappropriate to include any personal information about yourself. Also, try to phrase your questions so that they will be of general interest to other readers.

Saturday, June 17, 2017

IT IS EASIER TO CRITICIZE THAN CREATE

Before publishing any editorials or comments that defame the reputations of companies and people, and prior to making comments that are just plain wrong and devoid of facts, it is hoped an editor, comedian or political commentator will think ahead and realize the potential consequences. This relates to the editor's note on RenalWeb.com, June 16, 2017, and a Youtube clip by John Oliver.

Getting to a point where dialysis is commonplace and can be safely performed thousands of times a day is an accomplishment that involves tenacious patients, devoted doctors and teammates, and yes, dialysis corporations. Each player has a role, and as a witness to how hard it is to make all of this look easy, I can proudly respond to the cheer of a CEO recognizing exemplary teammates on their “Night of Honor.”

It is easy for the comedian or the journalist to stand outside and mock and disparage us, accentuate our flaws, and begrudge the benefits bestowed upon nearly a half a million persons. What is hard is to recognize where we came from, and in my opinion marvelous to see where we are going.

Before dialysis, persons with kidney failure simply died. Dialysis evolved from cellophane sausage wrappers to acrylic hollow fibers, from washing machines to proportioning machines, and from a crude plastic shunt to the observation that fistulae complicating war injuries were easier to cannulate. Its development was the convergence of technology and necessity, and in the beginning, it was not available to everyone. The tone was quite different than today, as most people did not qualify for dialysis in the 1960s. In 1972, Medicare was expanded to include dialysis care, and persons with “End Stage Renal Disease,” now enjoyed the gift of survival. Through the years that followed, a series of milestones resulted in a procedure that is now streamlined, routine, and still not perfect. But, to think this is an easy gain is illusory. This is a challenging field where gratification and joy are routinely mixed in with heartbreak and failure. We take nothing for granted.

We will be studying the Aethlon Hemopurifier®, a novel therapeutic device that targets the rapid elimination of viruses like hepatitis C and the tumor-secreted exosomes that can suppress the immune system in cancer patients.

Exosomes are vesicles created by the cell that can fuse with the cell wall membrane leading to the release of waste products. These products can be used as biomarkers for disease. However, the cell seems to use them for sending signals between cells or for waste management. Since the excreted exosomes can transfer "cargo" of molecules that may suppress the immune system, they may allow pathogens and tumors to adapt and grow. They may enhance angiogenesis and metastasis. Efforts are underway to further study the role of exosomes in disease pathogenesis. Meanwhile, we are collaborating with Athleon and DaVita Clinical Research to find ways to remove viral particles and ultimately exosomes from the circulation.

PUMP-A-LICIOUS

KICK-OUT KIDNEY DISEASEThe National Kidney Foundation presented Pump-a-licious at River Oaks Country Club, May 22, 2014. The show was hosted by Neiman Marcus. Drs. Stephen Fadem and Wadi Suki each received the Glass Slipper Award for their contributions to kidney care.

Thanks you, National Kidney Foundation, for selecting me as an honoree today. I could not think of a finer person to share this honor with than Dr. Suki, who has always served as my role model and inspiration.

In 1969, a first year medical student volunteered at the Children's Ward. There I met Floyd, a cute 4 year old. Bubbling over with joy to see us, he always raised his little arms to hug us. We cared for him sevral weeks before he dwindled and died. Floyd had kidney failure, but was not eligible for dialysis.

The moment of his death gave my career purpose - I vowed from then on that I would strive to help to kick out kidney disease. It has been a long journey - 45 years.

I have been most fortunate my wife, Joyce, has for the last 40 of these years, stuck by my side as a companion, the mother of our incredible children, my friend, my soul mate and my critic. Our life is rich and full of happiness, and to her and our family I express profound gratitude.

My career centers around Kidney Associates, DaVita, Baylor and volunteerism with organizations like NKF. It is all of you who deserve the credit, and to all of you that I owe a great deal. Thanks for contributing to what has been a fabulous career and life.

Receiving an honor for merit always challenges the recipient to continue living up to the distinction, and I pledge to always try to do so here.

Monday, February 27, 2012

...highly recommended to a broad range of readers - Nathan Levin

Nathan Levin reviews Issues in Dialysis

Current books on dialysis consists largely of two types of publications; one is handbooks of practical instruction for physicians, nurses, technicians, social workers and dietitians and the other is encyclopedic works emphasizing the physical, chemical and biological aspects of various types of dialysis and including the wide range of psychosocial issues characteristic of this interesting subspecialty of nephrology. An interesting new book, “Issues in Dialysis” edited by Stephen Z. Fadem brings together individual viewpoints on a variety of current topics. It is a substantial work of 20 chapters, generally very readable, and is a good representation of current opinion.

The book begins with the description of 20 milestones in dialysis (with emphasis on the US) by Fadem which incorporate technical progress, process, access development, dialysis as an industry, dosing of dialysis, ESAs and practice Guidelines, transplantation, and government action . Golper and Schreiber provide a powerful argument for an integrated approach to therapy in regard to modality choice and site of treatment, communication and education with patients is stressed. Amy Friedman focuses on the range of decisions implicit in the variable quality of donor kidneys and provides a novel analysis of the expectations of the stakeholders associated with transplantation including patient, surgeon, nephrologists to payer, etc. Chris Blagg contributes a characteristically polished history and evaluation of the Seattle home dialysis experience. Badve, Hawley and Johnson take up the must discussed question of clinical outcomes comparing PD and HD pointing out most evidence is derived from observational studies. In their Chapter on intensified dialysis in children, Thumfart and Muller present this approach as a promise to improve symptoms and psychosocial rehabilitation.

Victor Gura provides an impressive argument for development of a wearable artificial kidney, referring also to his considerable personal experience. In a thought provoking essay, Susan Bray deals fully with the issues involved in not automatically dialyzing everybody. She emphasizes the RPA guideline on withdrawal from dialysis and the concept of the “time limited trial”. Richard Glassock convincingly provides the basic arguments for the primacy of extracellular fluid overload as the major mechanism for development of left ventricular
hypertrophy, the difficulties faced in determining its degree and possible therapeutic approaches to its eradication. In one of the few Chapters devoted to basic science, William Mitch fully but lucidly describes the enzymatic mechanisms underlying muscle wasting in kidney disease as influenced by events occurring in chronic kidney disease such as acidosis, inflammation, increased glucocorticoid production, etc. Allon Friedman, answering the question of the value of serum albumin as a useful marker of nutritional status, convincingly demonstrates its importance as rather a marker of illness. The Chapter on the deregulated immune system in dialysis patients by Grabner, Pavenstadt, Lang and Reuter is important because of the relative novelty of such reviews but also because of its breadth of topics, valuable tables and extensive references. Over activation and malfunction of the immune system is demonstrated from the early stages of CKD until loss of kidney function occurs.

Hruska, Fang and Sugatani emphasize the close relationship in CKD patients between low turnover bone disease and vascular calcification and clearly describe the roles of bone regulatory proteins and new skeletal hormones and inorganic phosphorus concentrations. New therapeutic approaches are suggested. Perhaps the most comprehensive Chapter of the book is the 30 page update on anemia and kidney disease by Goli, Pinkhasov, Landry, Chait, Horowitz, Hollot, Shreshtha and Germain. It deals in detail with the physiology of erythropoiesis in CKD, current questions of ESA dosing and resistance, iron metabolism, hemoglobin variability current controversies and much else related to this field.

The somewhat neglected field of accumulation of toxic metals and trace elements in dialysis patients is examined by Yen, Lin-Tan,and Lin. They point out the importance of trace metals, particularly lead and cadmium, but also chromium, copper and vanadium as contributing to a variety of pathological processes in patients with kidney disease.

James Tattersall’s Chapter on adequacy of dialysis is a remarkably well balanced assessment of the meaning of the term and its application. Dose, different schedules, removal of solutes of various sizes, clearances in vivo and in vitro and normalization of such in HD and PD, various models of pool size and a list of relevant RCTs are lucidly discussed and practical advice given.

Syed and Peden provide a very useful essay on the AV fistula which includes its history and the approach to create and maintain fistulae and to handle dysfunction. They point to current investigations to reduce neointimal hyperplasia and the future represented by tissue engineered blood vessels. Anaya-Ayala, Davies and Reardon define the general considerations regarding CVD and its risk factors in dialysis patients before describing pre-and post operative management and outcomes. They suggest that prevention is the most effective treatment.

Dori Schatell reviews the concept of health-related quality of life as evaluated by various measures including that of the SF36 and the Kidney Disease Quality of Life. This detailed account is singular, CMS (US government) requirements for such measurements are detailed and practical use of the instruments is clearly presented. The book ends with a succinct discussion of integrated Renal Disease Care by Franklin Maddux initiated by the Institute of Medicine’s document “Crossing the Quality Chasm” and being developed by The US Department of Health and Human Services. The task involves, inter alias, patient population identification, care coordination, CKD and ESRD interventions and eventually introduction of accountable care organizations. These may be major advances in care in the US.

The book with its international authorship and its broad range of issues, presents a fascinating picture of current writing on dialysis. It is highly recommended to a broad range of readers.

Monday, October 31, 2011

I went to the Okavango Delta this summer. We were supposed to be hearing a discussion about the indigenous grasses of South Africa. Somehow I just couldn't focus. This photo typifies health care in the USA. We are all trying to follow an agenda, which is at best a blur when one gets sight of the big picture. We complain about the high costs of the transition to dialysis, yet...

82 percent of patients start dialysis with a catheter instead of a permanent access.

Saturday, October 15, 2011

Since 1988 the National Kidney Foundation has sponsored a symposium in Houston. It has always featured top experts. This year was no exception. Many new concepts were revealed to the Houston community of nephrologists, nurses, administrators, social workers and dietitians. Myles Wolf started the sessions, and presented key new data from his recently published JCI article J Clin Invest doi10.1172/JCI46122. This showed that FGF-23, a hormone that rises to keep the serum phosphorus in balance in CKD, was directly toxic to cardiomyocytes, leading to an increase in cardiomyocyte, hence left ventricular hypertrophy. This was independent of klotho, previously thought to be needed for FGF-23 activity. It was demonstrated with an antibody that neutralized FGF-23. Also, in animals treated with that antibody, 1,25 OH D3 levels normalized. This has several implications: 1) it makes it desirable to want to keep FGF-23 levels low in CKD – and since the antibody is not available as a pharmaceutical (yet), we should try to minimize inorganic phosphorus intake. 2) it suggests that vitamin D activation is impaired by FGF-23, not because of reduced renal mass.

Tom Golper’s talk highlighted a paradigm shift in thinking of long term strategies when planning dialysis therapy. He also brought out that in the elderly population with multiple comorbidities, the outcomes were no better with dialysis than without. There are now several studies demonstrating this NDT (2007) 22(7):1955-1962..

Allen Nissenson outlined the need to integrate health care. The current health delivery system that splits care among a variety of different providers and competing resources is wasteful, and even with the strictest varieties of health reform, will never be cost effective. It is not sustainable. The best system is to have an accountable organization manage the patient’s health care. Concerns that large non-renal groups, be they hospitals or health plans, will not focus on the care that our patients require, and that decision making is best made by those providers and physicians who are highly familiar with kidney patients' special needs.

Amy Friedman started her lecture by asking each of us to look around for a spare kidney, under chairs in bags - and they must be live kidneys. (None found). If we could not find any, she would have to give her talk. She started with the UNOS dialysis trends – there are over 112,000 people waiting for a transplant (UNOS). In her discussion, she went over terminology changes that were more sensitive to the feelings of donor family members whose loss led to the gains some of our patients enjoyed. (The concept of mourning transcends human experience, as evidenced by the National Geographic quality photographs she took in Puerto Rico of a gila monster grieving over the death of another). She focused on the need for more organ donation, particularly through using extended criteria donors – matching older patients who needed a transplant with kidneys that were recovered from a like population that might be too risky for a younger population. She also focused on the barriers to a successful transplant. Sadly, some of these barriers are regulatory. Doing special viral testing within a few hours of a transplant would only increase ischemia time, and lessen the changes for a successful kidney. Another conundrum revolves around outcomes management. According to outcomes criteria the late Steve Jobs, the well loved founder and CEO of Apple, would have been a poor choice for the liver transplant he received June 23, 2009 because he did not survive for three years afterwards. However, in the two years he did survive he introduced to the world amazing products, including the iPad many of us are using at this moment. There is, however, no app to tell us exactly who will and will not do well with a liver or kidney, and human input and sound clinical judgment are still invaluable.

The day ended with Dr. Emil Abdulhayoglu talking about the various types of AV access. In addition to the standard definitions, however, he explained in a simple and understandable way, the physics that leads to varying outcomes between the different types of access. He very skillfully explained the clinical assessment of a fistula, emphasizing the need to feel the thrill along the fistula tract. The consequences of venous scar build up are venous stenosis or obstruction. Scar formation can appear very early after surgery. One drawback is that the resultant stenosis interferes with the normal maturation of the fistula wall, and the venous wall never develops the muscular change that enables it to seal off after a needle stick. All too often we encounter an infiltration when attempting to cannulate a young fistula that has not properly matured. This failure to mature is likely the result of obstruction that is easily repaired through early intervention prior to the initial cannuation attempt.

A few hiccups with audiovisual equipment not working properly were mostly a nuisance, but did not interfere with the speakers' messages. Unfortunately, Tom Parker was unable to make the symposium as planned, and the audience missed hearing one of the finest doctors in our profession speak to how we can improve the care of our patients. But, Dr. Parker promises to reschedule his trip to Houston, and will be welcome at CKD2012.

Stephen Fadem is the CMO of Kidney Associates, Houston and the founder of The Nephron Information Center, http://nephron.com. He is a Clinical Professor of Medicine at Baylor College of Medicine and a DaVita Medical Director. Dr. Fadem is active in RPA, AAKP, ASN and NKF, lectures frequently and is involved in health policy